Provider Demographics
NPI:1104062462
Name:ADVOCATE ILLINOIS MASONIC MEDICAL CENTER
Entity type:Organization
Organization Name:ADVOCATE ILLINOIS MASONIC MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL OPERATIONS AND CHIEF NURSI
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:773-296-7001
Mailing Address - Street 1:3632 WIRTH RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3632 WIRTH RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2218
Practice Address - Country:US
Practice Address - Phone:219-923-1263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.247086282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access